Miscellaneous
________________________________
 Barricades & signs (yours) 
 MSDS information 
 Gas bottles or cylinders secured 
 Other__________________________ 
________________________________
________________________________
Personal Protective Equipment Required
 Hardhat 
 Safety glasses 
 Hearing protection 

 Gloves (leather, kevlar, mechanics & etc.) 
 Face shield 

 Goggles 
 Sleeves (leather, kevlar, welding & etc.) 
 Harness & lanyards 
 Reflective vest/high visibility clothing 
 Personal floatation device 
 FR or Nomex clothing 
 Flash protection 
 Respirator 
 LOTO lock 
 Other__________________________ 
Task Completion List
Y N All permits signed
Y N Work area cleaned
Y N All tools secured
Y N Locks have been removed
Y N Was anyone injured
Y N Was there a Near Miss
Plans to Eliminate or Control the Hazard
________________________________
________________________________
________________________________
___________/__________/
20__________ Date
____________________________________
Team Member
____________________________________
Supervisor Review
____________________________________
Task
Team Member Hazard Hunt
Notes & Comments
________________________________
Stop Hazards Dead
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Supervisor sign off
Miscellaneous
________________________________
 Barricades & signs (yours) 
 MSDS information 
 Gas bottles or cylinders secured 
 Other__________________________ 
________________________________
________________________________




Check for all potential hazards that
may occur during task 
List all identifiable hazards 
List all plans to eliminate hazards 
DISCLAIMER: This safety form is a sample
document provided by the AISC Safety
Committee to be used in the shop or field. It is
a sample form only and is intended to be
modified by a competent person to meet the
specific needs of your facility and operations.
AISC is not responsible for the risks involved
in using this form.
___________/__________/
20__________ Date
____________________________________
Team Member
____________________________________
Personal Protective Equipment Required
 Hardhat 
 Safety glasses 

 Hearing protection 
 Gloves (leather, kevlar, mechanics & etc.) 
 Face shield 
 Goggles 

 Sleeves (leather, kevlar, welding & etc.) 
 Harness & lanyards 
 Reflective vest/high visibility clothing 
 Personal floatation device 
 FR or Nomex clothing 
 Flash protection 
 Respirator 
 LOTO lock 
 Other__________________________ 
Task Completion List
Y N All permits signed
Y N Work area cleaned
Y N All tools secured
Y N Locks have been removed
Y N Was anyone injured
Y N Was there a Near Miss
Plans to Eliminate or Control the Hazard
________________________________
________________________________
Supervisor Review
________________________________
____________________________________
Task
Team Member Hazard Hunt
Notes & Comments
________________________________
Stop Hazards Dead
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Supervisor sign off




Check for all potential hazards that
may occur during task 
List all identifiable hazards 
List all plans to eliminate hazards 
List the Steps Required
to Perform the Task
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Equipment
 Working with hand tools 
 Working with power tools 
 Using equipment 
 Using gas cylinders 

 Other__________________________ 
Identify Hazards Personal Limitations
 No procedure for the task 
 Not trained on tools to be used 
 First time performing the task 
 Distractions in the area 
 Instructions not clear/understood 
 Other__________________________ 
List the Steps Required
to Perform the Task
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Equipment
 Working with hand tools 
 Working with power tools 
 Using equipment 
 Using gas cylinders 

 Other__________________________ 
Identify Hazards Personal Limitations
 No procedure for the task 
 Not trained on tools to be used 
 First time performing the task 
 Distractions in the area 
 Instructions not clear/understood 
 Other__________________________ 
Emergency Evacuation
 Evacuation signal 
 Evacuation route 
 Evacuation location 
 Communicating the plan 
General
 Housekeeping 
 Barricades & signs in place (others) 
 Hazmat & other chemicals contained 
& labeled
 Spotters required 
 Other__________________________ 
Permits Required
 Hot work 
 Confined space entry 
Ergonomics Hazards
 Awkward body positions 
 Too heavy/awkward to lift (over 50 lbs.) 
 Walking area not clean or uneven 
 Repetitive motion 
 Prolonged twisting or bending 
 Body parts in line of fire 
 Other__________________________ 
Work Environment Hazards
 Slipping or tripping hazard 
 Limited access/egress 
 Adequate lighting 
 Position of hands 
 Exposure to high/low temperatures 
 Exposure to steam/chemicals 
 Exposure to loud noise 
 Exposure to dust 
 Working over water 
Holes covered & indentified
Emergency Evacuation
 Evacuation signal 
 Evacuation route 
 Evacuation location 
 Communicating the plan 
General
 Housekeeping 
 Barricades & signs in place (others) 
 Hazmat & other chemicals contained 
& labeled
 Spotters required 
 Other__________________________ 
Permits Required
 Hot work 
 Confined space entry 
Ergonomics Hazards
 Awkward body positions 
 Too heavy/awkward to lift (over 50 lbs.) 
 Walking area not clean or uneven 
 Repetitive motion 
 Prolonged twisting or bending 
 Body parts in line of fire 
 Other__________________________ 
Work Environment Hazards
 Slipping or tripping hazard 
 Limited access/egress 
 Adequate lighting 
 Position of hands 
 Exposure to high/low temperatures 
 Exposure to steam/chemicals 
 Exposure to loud noise 
 Exposure to dust 
 Working over water 
Holes covered & indentified
 Others working below/overhead 
 Other__________________________ 
What are the Potential Hazards
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Eliminate the Hazards Working at Heights
 Harness required 
 Tie-off points identified 
 Materials & tools secured 
 Elevated work area complete 
(handrail, midrail, & toe boards)
 Planks & bed ladders tied down 
 Scaffold tagged & inspected 
 Ladders tied off 
Equipment & Tool Requirements
 Guards/proper attachments applied 

(ZES when changing) 
 Straps to secure tool, load, pipe & etc. 
 Daily inspection on all equipment 




 Others working below/overhead 
 Other__________________________ 
What are the Potential Hazards
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Eliminate the Hazards Working at Heights
 Harness required 
 Tie-off points identified 
 Materials & tools secured 
 Elevated work area complete 
(handrail, midrail, & toe boards)
 Planks & bed ladders tied down 
 Scaffold tagged & inspected 
 Ladders tied off 
Equipment & Tool Requirements
 Guards/proper attachments applied 
(ZES when changing) 
 Straps to secure tool, load, pipe & etc. 
 Daily inspection on all equipment